079200937-12-7-2022-15-AS-KHOS-CM5KFU-20221215065231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200937
Report Date: 12/07/2022
Date Signed: 12/07/2022 04:16:34 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/28/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20221128113357

FACILITY NAME:	AGING IN THE BAY		FACILITY NUMBER:	079200937
ADMINISTRATOR:	CHARMAINE MENDAROS		FACILITY TYPE:	740
ADDRESS:	4617 HIDDEN GLEN DR		TELEPHONE:	(925) 206-4770
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 2	DATE:	12/07/2022
		UNANNOUNCED	TIME BEGAN:	03:46 PM
MET WITH:	Charmaine Mendaros, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff yelled at resident
Facility staff restricted resident inside the room

INVESTIGATION FINDINGS:

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On 12/07/22 at 3:46PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, met with administrator and delivered investigation findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Facility staff yelled at resident
Investigation Finding: Unsubstantiated
During investigation, LPA conducted interviews with residents (R1, R2, R3). All residents denied being yelled at or being maltreated by staff (S1). Witness (W1) also stated she has visited the facility several times unannounced and did not observe staff (S1) yell at residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20221128113357

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AGING IN THE BAY	FACILITY NUMBER: 079200937
	VISIT DATE: 12/07/2022

NARRATIVE

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Allegation: Facility staff restricted resident inside the room
Investigation Finding: Unsubstantiated
Based on interviews and record reviews which were conducted, residents (R1, R2, R3) stated they were never restricted inside their bedrooms by staff (S1). On 12/01/22, R1 denied to LPA being restricted inside her bedroom by S1. W1 stated she did not observe any resident being restricted inside their bedrooms. Residents state they are able to move around the facility as often as they want without restriction. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

No deficiency cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

LIC9099 (FAS) - (06/04)

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